What Caused the Health Care Failure?

The Washington Post ran an analysis piece the other day entitled, “Obama’s Struggle with Health-Care Reform Echoes Clintons’ Failure in 1994.”

That’s exactly the headline that—when they were mapping their strategy for health care reform a year ago—the Obama people hoped to avoid. They had studied carefully the Clintons’ health care disaster 16 years ago and patterned their political approach to prevent history from repeating itself.

Well, it seems history is repeating itself—but for opposite reasons.

I’ll note here for the record that a health care bill may still pass, but even the most optimistic supporter of reform would have admit it ain’t looking good right now.

The Post story is worth a read. It ticks off a list issues that have undermined health care reform: The bill took too long to pass, giving opponents amble time to kill it; the bill was too big and too complex, which made support hard to sustain; Americans want health care reform in a general sense, but often don’t like the specifics.

But there’s a piece missing from the Post analysis.

The Obama staff has talked publicly many times about their interpretation of why the Clintons’ plan failed. One main reason, they said, was because Clinton proposed one central bill that became one large target for opponents to repeatedly attack.

That lesson was one reason the Obama people went the opposite way: They never had their own plan, just broad outlines of what they wanted. They let Congress fill in the details. The idea was to prevent opponents from launching a hostile campaign against a single bill. Instead there was a set of competing House and Senate bills, similar in design, but which differed on some key points (like whether to include a public option). So, technically speaking, there was no such thing as Obamacare.

The irony is, in the end, the lack of a central proposal became a huge problem. Opponents of reform still attacked “Obamacare,” even if, in the strictest sense, there was no such thing.

And because there was no single proposal, Americans never had a good idea of what health care reform entailed and how it would impact their lives.

That remains true. If you ask 10 people on the street what exactly Obamacare does (expand Medicaid, use health insurance exchanges, provide subsidies for people to buy private insurance), I would bet very few could tell you the details or if the plan would help them.

Since there was no one plan, no one—Obama included—ever sold reform to Americans. Where was the presidential barnstorming tour for health care? Why didn’t Obama spend a month visiting every state, speaking in front of backdrops that read “health care now!” and holding town-hall meetings to explain the plan, to talk to people with health care horror stories and to make the case for reform? President Bush was a master at that kind of campaign

I suspect it was the lack of a single plan that prevented from Obama using the bully pulpit effectively. Right up until the House and Senate passed their bills, it wasn’t clear what health care reform really was—would there be a public option? How much would the subsidies be? Would Cadillac plans be taxed?—and Obama seemed reticent to endorse any particular policy.

If no health care bill passes, we’ll probably look back on this diffuse approach as a huge mistake.

Obama may have learned the lesson of 1994, but he could very well end up with the same miserable result.